When you are finished completing this application, please copy it, and email back to us at
Or print and mail to Independence Empowerment Center, 9001 Digges Road, Suite 103, Manassas, VA 20110
Personal Assistant Application
Upon completion and return of this form, your name will be added to the IEC Personal Attendant Registry.
Independence Empowerment Center DOES NOT EMPLOY/HIRE Personal Attendants.
YOUR EMPLOYER WILL BE THE INDIVIDUAL YOU ASSIST.
Date Available to begin work:
Day Time Phone:
Physical&/or Mailing Address:
1. Please circle all Areas you are able to work in: FAUQUIER COUNTY MANASSAS MANASSAS PARK
WOODBRIDGE GAINESVILLE BRISTOW NOKESVILLE DUMFRIES OTHER:
2. Are you a licensed driver? 3. Do you have reliable transportation?
4. Are you a Certified Nursing Assistant (CNA)? 5. Are you able to do heavy lifting?
6. Are you able to do light lifting? 7. Are you interested in Part Time or Full Time?
7. Would you be available to assist persons if they have an emergency need for an assistant?
8. Would you be interested in a live-in position?
I understand that I will have to complete a Hire Packet and Criminal Background check for each separate employer that hires me. I will also have to provide appropriate identification.
I understand that I will not be employed by IEC but I do give permission to IEC staff to distribute my name and contact information to potential employers.
I verify that all information above is true and correct and that it is my responsibility to contact IEC if I would like my contact information to be removed from the IEC Personal Attendant Registry.
_________________________________ ___________________________ _________________________
Type/Print Name Signature Date